Nearly three out of ten under-five children in Indonesia were stunted [1]. The high stunting rate of under-five children in Indonesia is worrisome that government is focusing to reduce the stunting rate. The National Stunting Strategy states that there are five pillars of stunting prevention, i.e.

• Commitment and vision of the nation’s leaders

• The national campaign focusing on behavioral change, political commitment and accountability

• Coordination and consolidation of national, regional and community programs

• Encouraging food security policies

• Monitoring and evaluation [2]. These strategies require collaboration between ministries or institutions to accelerate the stunting prevention efforts. 

The World Health Organization (WHO) defines ‘stunted children’ as those whose height-for-age is at least two standard deviations below the WHO Child Growth Standards Median [3]. Stunting has long-term consequences not only on individual’s health, but also the child’s cognitive development and productivity in the adulthood [4,5]. Stunting can be caused by many factors, such as chronic undernutrition, infectious diseases and environmental risks [6]. Chronic undernutrition in a long term can lead to stunting, it may start as early in pregnancy, infancy and early childhood. Therefore, nutrition intervention in the early phase is an important solution to prevent stunting, particularly before the age of two [7]. 

Generally, intervention to prevent stunting can be performed by direct or indirect interventions. Breastfeeding and food supplements are examples of direct interventions for children with undernutrition. While interventions targeting family planning or disease management are part of indirect interventions. The Banyumas Regency Government took an initiative to implement a specific nutrition intervention for undernutrition children. They developed a comprehensive nutrition program, which include clinical examination and routine child weight recording by cadres or midwives, food supplements in the form of 1.5 kcal/mL liquid products and activities monitoring by cadres or midwives. The liquid-based product (1.5 kcal/mL) basically consists of: 150 kcal of energy, 3.4-grams of protein, 18.8 carbohydrates, <0.025-grams of lactose, 6.8-grams of fat, 1.5-grams of fibre and an osmolarity of 440 mOsm/ L. The consumption of these liquid-based products for 28 days has increased the mean weight and height of children by 0.64 kilograms and 0.47 centimeters, respectively [8]. Nevertheless, the liquid product is difficult to store, prone to damage and more expensive than powder-milk product. Therefore, it is considered whether this powder product can be an alternative to liquid products. A cost-comparison analysis was performed to calculate the cost between liquid- versus powder-based nutrition intervention to prevent stunting among undernutrition children. Up to date, there has been no study comparing the cost and effectiveness of liquid- versus powder-based product, hence, we aim to provide a transparent assessment of the costs related to nutrition intervention that can be done in 28-days period.

Data Sources

The Banyumas Regency Government had conducted a feeding intervention program for special medical purposes. The program assessed 40 under-five children with poor nutrition intake who resided in Banyumas and required specific intervention in year 2019. The intervention was performed over 28-days period. All children in the program received liquid-based product. The cost data were obtained from the result of in-depth interview with program managers at 33 Community Health Centers (Puskesmas). While cost data for powder-based product were obtained from market survey.

Effectiveness of Liquid Versus Powder-Based Product

In this study, we did not assess the clinical effectiveness of liquid- versus powder-based products. Using the assumption of similar nutrient content with the liquid-based product, we assumed the effectiveness would also be similar. The liquid-based product has energy density of 1.5 kcal/mL; while the powder-based has 1 kcal/mL. Other distinguished character is consistency of the product. For powder-based, the consumers need to mix it with water before they can consume it.

Interventions

The nutrition intervention program includes three main phases, i.e.

• Pre-intervention

• Intervention

• Post-intervention

The pre-intervention activities include clinical examination and anthropometric measurements. Meanwhile, intervention activities include the provision of nutritional products in the form of 1.5 kcal/mL liquid products and the last phase, i.e. post-intervention, consist of monitoring and evaluation activities. Should nutrition intervention with powder-based product be performed, the activities in the program are similar and have no difference with liquid-based product. Ethical approval was granted for the cost analysis of Banyumas Regency Government’s nutrition intervention program by the Faculty of Medicine, University of Katolik Indonesia Atma Jaya (No. 03/12/KEP-FKIKUAJ/2020).

Measuring intervention Costs

All costs incurred from the Banyumas Regency Nutrition Intervention Program over a 28-days period were measured from the perspective of the providers. A bottom-up approach was employed to calculate each component of resource use. All resources for the program were identified and multiplied by the quantities of the used resources. The costs were classified into two categories, i.e. fixed costs and variable costs. Variable costs are costs that are proportional to the number of services provided per child who receives an intervention, the more children who are intervened, the higher this cost. While fixed costs (fixed costs) are costs that are fixed in number even though there is an increase in the number of children being intervened. It should be noted that the estimated cost in this study that is calculated is the total real cost incurred during the implementation of the activity without considering the depreciation side per year, even though the tool used is only for 1 month.

The costs were identified as follow: 

• Training Costs: The cost of training cadres and midwives in the implementation of nutrition intervention program, included the fee for trainers and consumption costs 

• Socialization Costs: The cost of promoting the nutrition intervention program to the community

• Monitoring Costs: the costs for monitoring activities, consisted of transportation costs for midwives/cadres to do home visit and costs for reporting

• Equipment Costs: The cost of equipment used in the nutrition intervention program, included the cost for product storage in the cupboard and special room for storage

• Facility Costs: The cost for purchasing scales to measure body weight and height

• Product Costs: The cost for providing nutritional products by a number of children participating in the program

Validation of Intervention Costs

The resources were valued in monetary terms using standard methods. The primary outcome was the net cost of each category comparing liquid versus powder based product in the nutrition intervention program. The cost of liquid-based product was derived from primary data collection, while the cost of powder-based product was obtained from the price listed on the market place. The training costs were estimated based on an hourly rate of trainers which was obtained through interview with Puskesmas staff in the Banyumas Regency Nutrition Intervention Program. The costs for human resources were calculated as per the Government Regulation for one-month fee. For the product, the cost of liquid-based product was derived from the Banyumas Regency nutrition intervention program. While the cost of powder-based product was obtained from the price list on the market place. The highest retail price was used in this calculation.

The breakdown of the total costs for nutrition intervention comparing liquid- versus powder based product over 28-days period is contained in Table 1.

Table 1: The Costs for Nutrition Intervention Program

Total costs were higher for the liquid-based product when compared to the powder-based product nutrition intervention program. The main cost driver in the liquid-based product nutrition intervention program was the product cost, consisting one-fourth of the total costs. While the findings were different in the powder-based product nutrition intervention program in which the main cost driver were equipment cost. 

If we breakdown the details of the product cost that had been calculated for 40 children, the unit cost was higher for liquid-based product, compared to powder-based. The unit cost of liquid-based product was 1,395,850 IDR. Meanwhile the unit cost of powder-based product was 602,640 IDR. The total cost was calculated for 28-days intervention program, with the cost difference was 31.728.400 IDR or 793.210 IDR per child.

This study reports the results of a micro-costing study of nutrition intervention program comparing liquid- versus powder-based product. To our knowledge, this study is the first to report the cost-analysis of nutrition intervention comparing those two products. There are various of nutrition intervention for undernutrition infants and children. Complementary feeding is a common intervention conducted for those aged between 6 and 24 months. Provision of complementary feeding for those population living in food-insecure households were considered effective in improving height-for-age Z score (SMD 0.39; 95% CI: 0.05-0.73) and weight-for-age Z score (SMD 0.26; 95% CI: 0.04-0.48). However, the available evidence is not sufficient to recommend the intervention in food secure populations [9,10]. 

In this study, we did not calculate costs for transportation of the patients since the products were being delivered by cadres/midwives to the patient’s home. Using the perspective of providers, this study aims to describe the costs required for nutrition intervention program. The result from the Banyumas Regency Nutrition Intervention program calculated the total cost for 40 children over 28-days period, which resulted in 219,817,500 IDR.8 The amount of total costs will certainly increase along with the changes of product costs. In this study, the costs for pre-intervention occupied the biggest portion of the total costs (51%). If we plotted all costs as fixed costs, except for product costs. Health providers could estimate the budget necessary for nutrition intervention program, similar to this. 

The main difference between liquid- versus powder-based product is the practicability in mixing the formula with water. Several factors are associated with the best practice in mixing the product with water, for instance the aseptic technique, storage system, temperature control and consumables (infant bottles) [11,12]. It has been recommended by the WHO and other national authorities to use water heated to at least 70oC to dilute powdered milk, to consume milk directly after being prepared and to store reconstituted formula <5^oC [13-15]. These factors may affect the practicability in real life, including additional needed cost for water to dilute the powder, nevertheless, these had not been taken into account in this cost analysis study. 

The use of micro-costing approach in this study is the main strength of this study. Nevertheless, it is important to acknowledge that the estimates were derived from specific intervention in a setting (Banyumas Regency) that might not be applicable to different setting. During data collection for costs data, we found that each Puskesmas applied different standards for the cost of human resources. Some Puskesmas assumed that the cost of human resources was not applicable since the nutrition intervention program was considered as part of their daily tasks and therefore, additional fee was not necessary. 

In regard to the clinical effectiveness of liquid- and powder-based products, there is still limited evidence to support the differences between these two products. The similarity in terms of nutritional content, despite different energy density, was used as the basis to assume similar effectiveness. 

Estimating the product costs, we used different approach since no data were available for the powder-based product. The calculation of powder-based product was based on the highest retail price, surveyed from several market place. The price in this case included the profit component and might not be comparable with the cost of liquid-based product. However, this approach was used because there were no alternative solutions for cost comparison.

This cost analysis suggests that powder-based product can be used as an alternative solution to replace liquid-based product because of similar nutrient contents and lower costs. This would save cost 793,210 IDR per child, compared to liquid-based product.

Funding

This research was funded by Danone Specialized Nutrition Indonesia.

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